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Mental Health and Social Characteristics of the Homeless: A Survey of Mission Users

PAMELA J. FISCHER, P H D , SAM SHAPIRO, BS, WILLIAM R. BREAKEY, MD, JAMES C. ANTHONY, P H D , AND MORTON KRAMER, SCD Abstract: Selected mental heeilth and social characteristics of 51 homeless persons drawn as a probability sample from missions are compared to those of 1,338 men aged 18-64 years living in households from the NIMH Epidemiologic Catchment Area survey conducted in Eastern Baltimore, Differences between the two groups were small with respect to age, race, education, and military service but the differences in mental health status, utilization patterns, and social dysfunction were large. About one-third ofthe homeless scored high on the General Health Questionnaire which measures distress, A similar proportion had a current psychiatric disorder as ascertained by the Diagnostic Interview Schedule (DIS), with the homeless exhibiting higher prevalence rates in every DIS/DSM III diagnostic category compared to domiciled men. Homeless persons reported higher rates of hospitalization than household men for both mental (33 per cent vs 5 per cent) and physical (20 per cent vs 10 per cent) problems but a lower proportion received ambulatory care (41 per cent vs 50 per cent). Social dysfunction among the homeless was indicated by fewer social contacts and higher rates of arrests as adults than domiciled men (58 per cent vs 24 per cent), including multiple arrests (38 per cent vs 9 per cent) and felony convictions (16 per cent vs 5 per cent). Implications of these findings are discussed in terms of research and health policy, (AmJ Public Health 1986; 76:519-524,)

Introduction Much has been written about the mental health service needs of homeless people,' but the literature contains few reports which provide detailed information on their mental health status. This report presents epidemiological data from a survey of mission users conipared with data gathered using identical methods from a larger sample of domiciled men surveyed in the same community. Once resident primarily in run-down areas of inner cities known as "skid rows,"^ homeless people have now dispersed throughout urban areas, becoming more visible than at any time since the Great Depression of the 1930s. Contemporary homeless populatiphs appear to be more heterogeneous than those of skid rows. New studies ofthe homeless point to the emergence of at least four subgroups based on a combination of personal attributes and life history,* i.e., the chronically mentally ill,''^ street people,'"" skid row alcoholics,'^"'^ and the situationally homeless such as unemployed, evicted and transient persons.^'* While some overlapping of subgroups is inevitable, persons in the four groups are distinguishable according to their different psychosocial characteristics and patterns of coping with homelessness. The recent increase in the numbers of homeless has been attributed to several factors including high unemployment,*'? decreases in public support programs,' changes in the structure of American families,'* and the unavailability of low cost housing,'"'* A large measure of the blame for increasing the numbers of mentally ill among the homeless is being djrected toward deinstitutionaiization of mental patients.""" By restricting admissions to state facilities and by discharging chronically ill peop|e* fo care in community settings, the locus of treatment fof large numbers of patients has been shifted from the hospitals to the community. However, adequate community resources have not been
Address reprint requests to Pamela J. Fischer, Assistant Professor, Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, 600 N, Wolfe Street, Baltimore, MD 21205. Dr, Breakey is Associate Professor in that same department, Mr. Shapiro is Professor Emeritus, Department of Health Policy and Management; Dr, Anthony is Associate Professor, and Dr, Kramer is Professor Emeritus, both with the Department ofMental Hygiene, all three with the School of Hygiene and Public Health at ,fHU, This paper, submitted to the Journal I^ay 10,198S, was revised and accepted for publication September 24, 1985, 1986 American Journal of Public Health 0090-0036/86$ 1,50

made available to provide the needed ambulatory care with the result that some former patients "fall through the cracks" in the system, many ending on the streets.^" More than any other group, the mentally disordered have been linked in the minds ofthe public to the production of aberrant individuals: the image ofthe homeless person has changed from the public inebriate to the potentially dangerous "crazy" person. The degree to which this stereotype has real substance is unclear. The picture of the homeless population which is emerging from contemporary research is of a younger population, with histories of frequent arrests and contacts with the mental health system."'^'"^' Recent studies have indicated that a substantial proportion of homeless persons report histories of psychiatric hospitalization and exhibit current psychiatric symptomatology.'''-^* However, differences in definitions of populations, sample selection, diagnostic criteria, and screening methods have produced wide variations in estimates of prevalence. Methods
Eastern Baltimore Epidemiologic Catchment Area Study Design

This report examines selected sociodemographic and health characteristics of 51 homeless persons drawn as a probability sample for the National Institute ofMental Health (NIMH) Epidemiologic Catchment Area (ECA) program conducted in Eastern Baltimore.^'"^' The ECA program was designed to provide information on relationships between a community's prevalence and incidence of mental disorders, an array of personal and health characteristics, use of health and mental health services, and sources of care. Five geographic areas were defined in various parts ofthe United States. In each area, face-to-face baseline household interviews were conducted with probability samples of 3,(X)O-3,5OO community residents aged 18 years and older and 500 residents of institutions such as mental hospitals, nursing homes, and prisons. In Baltimore, a supplemental study was designed to augment the core ECA study by providing a sample of those persons living in settings not readily classifiable as households or institutions and who were expected to bear a disproportionate burden of mental illness. This sample included 51 homeless persons located in the survey catchment area. The core of the ECA survey instrument was the Diagnostic Interview Schedule (DIS),^' developed for use by

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trained lay interviewers, including a field, version of the Mini-Mental State Examination,^"* a standardized measure of cognitive impairment. Data from the DIS are analyzed using a computerized algorithih to derive DSM III diagnostic categories'' and classify persons by recency of meeting criteria for a disorder. The questionnaire also included a 20-item form adapted from the General Health Questionnaire (GHQ).'* The number of positive GHQ symptoms provides a gradient of probability of having a diagnosable psychiatric disorder; in this study the identification of a high probability group is based on a score of four or more. Since the GHQ covers current distress, it corresponds generally to the current or one-month case finding period for the DIS. In addition, the questionnaire covered other characteristics of community residents. These included socioeconomic characteristics, physical health status, use of psychotropic medications, life events, social supports, arid use of health and mental health services. The recall period was six months for ambulatory care and 12 months for inpatient episodes. Slight modifications were made to the questionnaire to tailor it to the respondents in the study reported here, e.g., remove inappropriate references to households, but in substance the survey instrument was otherwise identical to that administered to the Baltimore household sample. The Eastern Baltimore EC A site is composed of a large, densely populated urban area of Baltimore City covering three contiguous mental health catchment areas with a combined population of 241,000. As in the other ECA sites, a representative sample of householders aged 18 years and older was interviewed. All measures presented here for the household sample are weighted to take into account difiFerential sampling rates, response rates and the decennial census counts by age, race, and sex. This report compares findings from the sample of 51 homeless individuals to the sub-group of 1,338 males under 65 years of age interviewed in the Baltimore ECA household survey. Tests of statistical significance were applied using the chi-square statistic with Yates' correction for continuity. The results represent approximations in view of the fact that a complex sample design was applied in the case of the household sample. Actually, for many characteristics the margin between the two groups is so large there can be little question about the existence of a niajor difference. Sample of Homeless Persons Inherent in the ECA program was the concept of a geographically defined catchment area. Because homeless persons are urban nomads, and thus by definition do not belong to any specific catchment area, problems were encountered in establishing definitional criteria for the sampling pool. The US Bureau of the Census defines residency by where homeless persons sleep at night and key informants indicated that the homeless inhabit fairly circumscribed "home" ranges bounded by walking distance from soup kitchens and missions. Consequently, homeless persons found in all missions within the catchment area were considered to be eligible for sampling as "residents". Eour missions were located within the catchment area. On specified nights, interviewers went to the missions and randomly selected respondents for interview. Psychiatric symptomatology was not a selection criterion. The missions were open to anyone seeking a bed at nominal or no cost but because they were open only during the night (roughly 5:00 pm to 7:00 am) and have to maintain a schedule of activities. 520

e.g., religious services, dinner, showering, and lights out, the time period in which interviews might be conducted was considerably restricted. It was impossible to interview all respondents during one night. Consequently, sampling was spread over two or three nights for each mission. Because it was not feasible to roster the sheltered guests ahead of time, bed size of each mission was used to estimate the number of "residents". A sampling ratio of 1:5 was applied to each rnission's guests. In order to eliminate problems of duplication of respondents across the interview nights, a different portion of the alphabet was used on each occasion to define the sample pool. The response rate was high (98 per cent); only one refusal was encountered, resulting in a total homeless sample of 51 individuals. Respondents were offered a small gratuity ($5) which was judged to be a powerful incentive to participate in the study among members of this low resource group. The interview took on average one and one-half hours to administer to the homeless and one and one-quarter hours to household survey respondents. The field operations of the homeless study were conducted during the winter of 1981-82, roughly midway through the Baltimore ECA survey work, and the homeless study interviewers were the same as the household survey interviewers. This sampling strategy was considered to be the best alternative to other possible means of identifying the homeless population, e.g., through field observations of street people. However, it is recognized that bias was introduced in favor of males in that three ofthe four missions located in the catchment area restrict their services to men. The one women's residence had only 12 beds. Moreover, while the homeless sample accurately portrays the mission population of the catchment area, it does not necessarily represent the universe of homeless persons, some of whom, e.g., street people, may never frequent missions. Results Sociodemographic Characteristics of the Homeless Sample The homeless were virtually all male (94 per cent) due to the structure ofthe missions and only 2 per cent were 65 years or older, compared to 15 per cent of the males in the household sample. Therefore, the subgroup of men under the age of 65 years from the household survey was considered to be the most appropriate comparison group for the sample of the homeless. Consequently, all ofthe following observations on household males refer to this subgroup of males aged 18-64 years. The homeless did not differ importantly in terms of age, race, education, or military service from the household males aged 18-64 years. However, there is some suggestion that fewer ofthe homeless were very young adults and fewer had completed high school (Table 1). Less than one-fourth ofthe homeless had resided in Baltimore less than six months, and nearly 60 per cent had lived in Baltimore for 10 years or longer. Sixty-two per cent of the homeless persons reported spending most of their time within the catchment area, and the majority (80 per cent) reported staying in the city year-round rather than migrating for part of the year. Seventy-nine per cent planned to return to a mission to sleep on the night following interview and 14 per cent planned to be "on the street." Household males reported median annual personal incomes around $7,000 compared to under $2,000 for the homeless (Table 1). One-third of the homeless reported receipt of some form of public support compared to about
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TABLE 1Selected Sociodemographic Characteristics of Homeless and Household Survey Respondents (%) Household Males Ages 18-64' TABLE 2Sociai Support Networks of Homeiess and Household Survey Respondents (%) Househoid Maies Ages 18-64'



Network Member


Age (years) 18-24 25-*4 45-64 65+ Median Race White Non-White Sex Male Female Education (years) 0-8 9-11 12 13+ Military Service Veteran Vietnam Veteran Employment"" Working" Employed" Unemployed' Unable to work" Retired or idle" Pubiic Support Unemployment Insurance Benefits Social Security (Non-disabiiity) Disability Public Assistance No Pubiic Support"" (N)

11.9 49.0 37.3 2.0 38.0 52.9 47.1 94.1 5.9 19.6 39.2 19.6 19.6

22.6 43.1 34.3


61.4 38.6 100.0

Marital Status" Married Separated Widowed Never Married Number of Relatives'^ None" 1 2-3 4-5

0.0 33.3 5.9 60.8 31.4 23.5 29.4 3.9 11.8 45.1 5.9 21.6 15.7 11.8 68.6 15.7 15.7 0.0 (51)

48.4 2.4 14.6 34.6 4.2 7.6 23.7 20.7 43.7 6.9 5.8 17.7 20.6 48.8 31.3 24.2 18.9 25.6 (1337)

Number of Friends'^ None" 1 2-3 4-5

17.1 29.1 28.5 24.9

Number of Confidants' None" 1 2 3 (N)

51.0 17.6

40.7 13.0 78.9 71.1 7.5 6.4 7.2' 4.1 4.0 7.8 4.0 82.7 (1338)1

21.6 17.6 33.3 9.8 35.3

'Weighted data. "p <.OO1 (x2). 'Number ot friends, relatives or confidants with whom respondent maintained regular contact.

0.0 5.4 14.3 17.9 66.7 (51)

'Weighted data, "p <.O1 {x% 'Based on activities reported for the week preceding interview. ''Inciudes responses "empioyed". "keeping house", "school". "Salaried employment only. 'Included responses "lay off", "looking". 'Includes response "disabled", "therapy or day care", "hospitalized", "jail", "includes responses "retired", "other" (no specific activities e.g., hanging around). '"Other" category not defined for household survey respondents. 'Percentages vyere calculated excluding missing values which did not exceed 2% in any category.

were more than twice as likely to have been arrested as an adult (58 per cent) than household men (24 per cent), were more likely to have experienced multiple arrests (38 per cent vs 97 per cent), and were more likely to report felony convictions (16 per cent vs 5 per cent). A further breakdown of these data was not possible. To place these rates in perspective, the Baltimore Police Department crime statistics for Baltimore City show that in 1983 there were 18 arrests per 100 men aged 18-64 years; 35 per cent of all these arrests and 25 per cent of the arrests of homeless persons were for index crimes (murder, rape, assault, etc.). Mental Morbidity Thirty-seven per cent of homeless persons received a DIS diagnosis of a current DIS/DSM III mental disorder as compared with 18 per cent of household males (Table 3); nearly 80 per cent of the homeless were diagnosed as having had disorders at some time in their lifetime compared to around 40 per cent ofthe male household sample. For every disorder category, the prevalence was higher among the homeless; the disorder with the highest prevalence in each group was substance abuse but twice as many homeless were so affected. There was also a high prevalence of antisocial personality and cognitive impairment among the homeless compared to household men. Thirty-five per cent ofthe homeless had GHQ scores that indicated relatively high probability of psychiatric disturbance (score 4 and above), about three times the rate found among household meh (Table 3). Among homeless persons with these GHQ scores, half might be regarded as being moderately djsturbed (scores of 4-8) and half as being severely disturbed (scores of 9-20). However, in the household sample the reverse obtained with twice as many men scoring between 4 and 8 as scored 9 and above.

one-fifth of household males. None ofthe homeless reported unemployment benefits despite the third who reported being unemployed, and none reported receiving aid from more than one type of program. Social Networks The homeless, not surprisingly, exhibit impoverished social networks (Table 2). While almost half of men in the household sample were married at time of Interview, none of the homeless reported being currently married. Moreover, nearly twice as many of the homeless as household men had never married. Substantial proportions of the homeless reported no regular contact with friends or relatives and had formed no confiding relationships. Criminal History The homeless exhibited a pattern of juvenile arrests similar to that of household males, with about one-fifth having been arrested in their youth. However, the homeless
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TABLE 3Prevalence of Mentai Disorder as indicated by Distribution of DiS/DSiU III Disorders and Grouped GHQ Score among Homeiess and Househoid Survey Respondents (%) Homeless DIS Diagnosis One Month Six Months Lifetime Household Males Ages 18-64" One Month Six Months Lifetime

Any Disorder Substance Abuse/Dependence Schizophrenic Disorders Affective Disorders Anxiety/Somatoform Disorders Antisocial Personality Cognitive Impairment No Disorder (N) GHO SCORE"' 0-3 4-8 9-20 (N)

37.3 19.6 2.0 2.0 19.6 9.8 7.8 62.7 (51)

45.1 31.4 2.0 2.0 21.6 11.8 7.8 54.9 (51)

78.4 70.6 2.0 13.7 39.2 15.7 7.8 21.6 (51)

18.2 9.3 0.3 1.5 7.8 1.1 2.3 81.8 (1338)

22.8 12.5 0.4 1.9 10.3 1.5 2.3 77.3 (1337)

41.6 28.0 0.6 3.2 21.5 4.7 2.3 58.3 (1337)

64.7 17.6 17.6 (51)

87.5 8.5 3.9 (1307)

"Weighted data, "p <.OO1 (x2). Prior population studies have indicated that ascending scores on the GHO are associated with increasing probability of being diagnosed by a psychiatrist as mentally ill. Scores 0-3 are interpreted as iow probabiiity; 4 and above are high probability of disorder.

Health and Mental Heaith Service Utiiization

According to self-report, 39 per cent ofthe homeless felt themselves to be in poor health compared to 21 per cent of household men, but similar proportions of both groups reported chronic conditions. In addition, for the preceding three months, 20 per cent of the homeless reported trauma (e.g., were mugged); 4 per cent had been bitten by an animal; 10 per cent had skin ulcers; and 18 per cent reported infestation by lice or other parasites. The proportion seeking care for these conditions ranged from 20 to 50 per cent. Two-thirds of the homeless had no form of health care coveragemore than three times the rate found among men in the household sample. One-third of the homeless were Medicaid enroUees and 4 per cent were covered by Medicare compared to less than 10 per cent of household men under age 65 enrolled in either program. Nearly three-fourths of household men but only 2 per cent of the homeless had private insurance coverage for physicians' services. Of the homeless who reported a usual source of care, three-fourths relied upon a general hospital with major dependence on the emergency room (Table 4). Almost none identified a private practitioner as their usual source of care whereas nearly half of household men reported this source. Similar proportions of homeless and household men reported that they received no ambulatory health care during the six months prior to interview (Table 4). Among those reporting any care during the period, the homeless were fairly evenly divided between ambulatory medical care and ambulatory mental health care and the bulk of these mental health services were from mental health specialty providers. In contrast, the majority of men in the household sample who reported ambulatory care indicated it to have been of a general medical nature but those receiving mental health services were about as likely to receive it from general medical providers as from mental health specialists. Twice as many of the homeless as men in the household sample had been admitted to a general hospiteil for a physical problem for an overnight stay or longer at least once during

TABLE 4Usuai Source of Care and Utilization of Ambuiatory Health and Mental Health Care during Six Months Prior to interview by Type of Care for Homeless and Household Survey Respondents (%) Household Males Ages 18-64"

Utiiization Characteristic Usuai Source of Care" None General Hospital Psychiatric Hospitai (or MH residential facility) Ambulatory Medical Clinic (free-standing) Private Practitioner (N) , Utiiization of Ambulatory Care" No Care General Medical Only MH Services General Medical MH Specialist (N) Weighted data, "p <.O1 (x^).


36.7 49.0 4.1 8.2 2.0 (49) 58.8 23.5 17.6 2.0 15.7 (51)

7.9 39.0 0.0 7.9 44.8 (1310) 50.3 42.7 7.0 3.3 3.7 (1341)

the year prior to interview (Table 5). One-tHird of the homeless had a previous psychiatric hospitalization compared to only 5 per cent of male householders and three-fifths of those reporting inpatient episodes of care indicated it to have been recent, i.e., had occurred within the previous year. Discussion This sample of 51 homeless persons, although small, reveals attributes which distinguish them from household men in the same geographic area. Resource constraints prohibited a larger sample; accordingly, confidence intervals are very large. Nevertheless, a clear pattern emerges of differences in health and social characteristics. Alienation and particular patterns of psychopathology are the two principal characteristics which distinguish the
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TABLE 5Per Cent of Homeless and Household Survey Respondents Hospitalized In General Hospital for Physical Problems and In Hospital and Treatment Programs for Mental Health Problems Househoid Maies Ages 18-64

Hospitalization General Hospital'' (Physicai Problems) No admissions within year prior to interview One or more admissions (N) Hospitais and Treatment Programs" (Mentai Problems) Never Within year prior to Interview More than 1 year prior to interview (N) 'Weighted data, "p <.O54 (x2).


80.4 19.6 (51) 66.7 19.6 13.7 (51)

89.9 10.1 (1331)

95.0 1.0 4.0 (1312)

homeless from domiciled men. Whether alienation is a consequence of certain psychopathologies is unclear, but it would seem likely that this rejection of or exclusion from the normal social interactions ofthe wider community may have contributed to their becoming homeless. The GHQ and the DIS each identified about one-third of homeless subjects as probable psychiatric cases. Another important indicator was that one-third reported previous psychiatric hospitalizations, more than half within the preceding year. The magnitude of the differences between the findings in the homeless and household samples is striking. Surprisingly small proportions were found to have the major mental illnesses (schizophrenia, affective disorders, and cognitive impairment) that have been diagnosed more frequently in other studies of homeless populations.'''^^ However, the instruments used in this survey to identify psychiatric cases may not be well suited to the detection of persons with such disorders. The GHQ probes for non-specific symptoms of distress and there is some dissension regarding the sensitivity of the DIS for these mental illnesses.'^'*^''^ Other disorders that were diagnosed more frequently in our sampleanxiety/somatoform disorders, antisocial personality disorder, and particularly substance abusehave social and functional outcomes that may also be significantly disabling. It must be recognized that the sample was constructed from mission users and not from the homeless at large. It is not clear how the mission users differ from homeless people in general, but it seems probable that those who regularly sleep on the streets at night may have higher prevalences of mental illness. One ofthe difficulties in interpreting data from studies of the homeless is that different studies have examined different subgroups of the homeless population.' A substantial proportion of mission users were characterized as mentally ill and a third reported histories of previous psychiatric hospitalization, but there is insufficient information to identify them as victims of deinstitutionalization. Only a minority of the subjects in the mission sample conform to the traditional concept of a "skid-row" alcoholic, yet the high lifetime prevalence for substance abuse/dependence is striking. Determination of residency has important implications for obtaining human services, e.g., general public assistance. An important finding of this study is the long-standing
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attachment ofthe homeless sample to Baltimore City. These data, which are supported by findings reported from other cities,''"^' suggest that the homeless population is more typically a "native" rather than a transient group of people and thus should be considered to be eligible for services provided to other city residents as well as a group to be included in the process of planning for future services. The homeless in our sample were substantially more likely to be receiving public assistance or disability benefits than household men. However, in view of their low financial resources and other characteristics, the proportions receiving such help appear to be low. In summary, the homeless exhibit patterns of health service utilization that differ sharply from those of males of similar age in the same community. Determination of the contribution of subgroups (e.g., the deinstitutionalized vs others) to the total homeless population in terms of size, demographic composition, and morbidity is a critical area for future research. Psychosocial differences among subgroups and between sexes may have important implications for estimating health and other human services needs and developing more appropriate modes of delivering such services.
ACKNOWLEDGMENTS This research was supported by the Epidemiologic Catchment Area Program. The ECA program is a series of five epidemiologic research studies performed by independent research teams in collaboration with staff of the Division of Biometry and Epidemiology (DBE) of the National Institute of Mental Health (NIMH). The NIMH Principal Collaborators are Darrel A. Regier, Ben Z. Locke, and Jack D. Burke; the NIMH Project Officer is Carl A. Taube. The Principal Investigators and Co-Principal Investigators from the five states are: Yale University, UOl MH 34224Jerome K. Myers, Myma M. Weismann, and Gary L. Tischler; Johns Hopkins University, UOl MH 33870Morton Kramer, Sam Shapiro, and Ernest M. Gruenberg; Washington University, St. Louis, UOl MH 33883Lee N. Robins. John E. Helzer, and Jack L. Croughan; Duke University UOl MH 35386Dan G. Blazer and Linda K. George; University of California, Los Angeles, UOl MH 35865Richard Hough, Marvin Kamo, Javier Escobar, Audrey Bumam, and Dianne Timbers.

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Call for Abstracts for I APHA Late-Breaker Epidemiology Exchange Session I

The Epidemiology Section will sponsor a Late-Breaker Epidemiologic Exchange on Wednesday, October 1, 1986 at APHA's Annual Meeting in Las Vegas, NV. The Exchange will provide a forum for presentation of investigations, studies, methods, etc., which have been conceived, conducted, and/or concluded so recently that abstracts could not meet the deadline for submission to other Epidemiology Sessions. Papers submitted should report on work conducted during the last 6-12 months. Abstracts should be limited to 200 words; no special form is required. Abstracts should be submitted to Robert A. Gunn, MD Division of Field Services Epidemiology Program OflBce Bldg. 1, Room 3070 Centers for Disease Control Atlanta, GA 30333 Abstracts must be received by August 15, 1986.


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